Cedar Ridge Health & Rehab Ctr

Inspectors wroteBased on observation, interview and record review the facility failed to document when a multi use vial of Aplisol (Tuberculosis/TB testing solution) was opened. This has the potential to affect all 106 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain Sanitary conditions in the kitchen to promote safe food handling. This failure has the potential to affect all 106 residents residing in the building.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were safely transferred via mechanical lift, failed to ensure fall interventions were in place according to resident Care Plans, and failed to provide an appropriate shower chair resulting in a resident to sustain a fall for 4 of 7 (R22,R28, R54, R69) residents reviewed for accidents in the sample of 52. Findings Include:1. R28's admission Record print date of 3/11/26 documents R28 has diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, COPD (chronic obstructive disease), chronic atrial fibrillation, hypertension, polyneuropathy, depression, and anxiety. R28's MDS (Minimum Data Set) dated 1/19/26 documents R28 is cognitively intact and requires partial/moderate assistance with wheelchair transfers and showers. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide food and drink that is palatable, attractive, and at a safe and appetizing temperature for 6 of 10 residents (R9, R17, R20, R45, R58, R60) reviewed for palatable and appetizing food in the sample of 52.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely and complete incontinent care for 2 of 8 residents (R93, R96) reviewed for incontinent care in the sample of 52.

Inspectors wroteBased on interview, observation, and record review the facility failed to provide effective pain management for 1 (R10) out of 1 resident reviewed for pain in the sample of 44. This failure resulted in R10 experiencing ongoing pain during peri-care as evidence by visual and audible reports of pain expressed.

Inspectors wroteBased on Interview, Observation, and Record Review, the facility failed to provide dignity during feeding assistance and ensure resident call lights are within reach of the resident for 4 of 20 residents (R8, R65, R93, R94) reviewed for resident dignity in the sample of 44. The Findings Include: 1. On 1/26/25 11:45 AM, V6 (Restorative Certified Nursing Assistant/CNA) was seen standing between R65 and R93 at a dining room table. V6 stood and used her right hand to feed R93, then used her left hand to feed R65. R65's Care Plan, dated 1/23/25, documents R65 has a Self-Care Deficit with Interventions: Take to dining room for meals, Eating - Setup help / Cueing required. R65's Minimum Data Set (MDS), dated [DATE], documents R65 is cognitively intact and is dependent on staff for eating. 2. R93's Care Plan, dated 11/4/24, documents R93 has Self-Care Deficit with Interventions: [...]

Inspectors wroteBased on Interview, Observation, and Record Review, the Facility failed to provide feeding assistance to Activities of Daily Living (ADL) Dependent residents requiring feeding assistance for 4 of 8 residents (R11, R24, R37, R59) reviewed for feeding assistance in the sample of 44. The Findings Include: 1. On 1/26/25 at 11:45 AM, R24 was seen sitting at the dining room table with his lunch tray and was not touching his food. When asked about being the only staff member assisting residents, V6 (Certified Nursing Assistant/CNA) stated I usually have someone helping me but not sure where she is. R24 was just staring at his plate and did not pick up his fork to eat. V6 would see this and yell to R24, sitting at another table, to take a bite. R24's Care Plan, dated 11/8/24, documents R24 has Self-Care Deficit with Interventions: Eating - Setup help/Cueing required. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to supervise a resident with cigarettes, safely transfer residents using a mechanical lift, and implement fall interventions for 4 of 5 (R3, R41, R68, R94) residents reviewed for supervision.

Inspectors wroteBased on observation, interview, and record review the facility failed to do timely and complete incontinent care for 4 of 5 residents (R39, R41, R68, R79) reviewed for incontinent care in a sample size of 44. The Findings Include: 1. R79's admission Record, dated 1/27/25, documents R79 was originally admitted to the facility on [DATE] with diagnosis of Bipolar disorder, Depression, Hallucinations, Traumatic Brain Injury, Pancytopenia, Type 2 Diabetic Mellitus (DM), Thrombocytopenia, Urinary incontinence, Hydrocephalus, COVID, and Urinary Tract Infections (UTIs). R79's Care Plan, dated 1/30/24, documents R79 is incontinent of Bowel/Bladder. Interventions: Observe and record bowel and bladder pattern each shift, clean peri-area with each incontinence episode. It continues R79 has Self-Care Deficit as evidenced by: [...]

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to serve food with an appetizing appearance and taste for 7 out of 7 residents, (R61, R10, R15, R2, R87, R53), reviewed for Nutritive Value/Appearance, Palatable/Preferred Temperature in a sample of 44.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene and glove changes for 6 of 7 residents (R9, R27, R41, R65, R68, R93) reviewed for hand hygiene in the sample of 44. The Findings Include: 1. On 1/26/25 11:45 AM, V6 (Restorative Certified Nursing Assistant/CNA) was seen standing between R65 and R93 at a dining room table. V6 stood and used her right hand to feed R93, then used her left hand to feed R65. There was no hand hygiene seen done prior to or between assisting the residents. R65's Care Plan, dated 1/23/25, documents R65 has a Self-Care Deficit with Interventions: Take to dining room for meals, Eating - Setup help/Cueing required. R65's Minimum Data Set (MDS), dated [DATE], documents R65 is cognitively intact and is dependent on staff for eating. 2. R93's Care Plan, dated 11/4/24, documents R93 has Self-Care Deficit with Interventions: [...]

Inspectors wroteBased on interview and record review the facility failed to confirm the need for an antibiotic and failed to ensure a resident received all doses of the antibiotic(s) as ordered for 5 of 5 (R34, R39, R85, R89, R95) residents reviewed for the antibiotic stewardship program in the sample of 44.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to follow wound care orders for 1 out of 1, (R87), reviewed for quality of care in a sample of 44.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide treatment and services to prevent and/or heal pressure ulcers for 1 out of 1 resident (R10) reviewed for treatment/services to prevent/heal pressure ulcers in a sample of 44.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident is free from significant medication errors for 1 or 5 residents (R89) reviewed for medications in a sample of 44. Findings Include: R89's Face Sheet, original admission date of 10/04/24, documented R89 has diagnoses of but not limited to infection following a procedure, deep incisional surgical site, subsequent encounter, and local infection to the skin and subcutaneous tissue. R89's Minimum Data Set (MDS), dated [DATE], documented R89 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 14 out of 15 and is dependent on staff for transferring from bed to chair, chair to bed, and toileting transfer. R89's Care Plan, admission date of 12/26/24, documented R89 is at risk for complications related to (r/t) a wound infection and requires antibiotics. [...]

Inspectors wroteBased on interview, observation, and record review, the Facility failed to ensure staff were wearing the appropriate Personal Protective Equipment (PPE) and following the required infection control practices. This has the potential to affect all 101 residents living in the Facility.

Inspectors wroteBased on observation, interview and record review, the Facility failed to prepare, and serve food in a manner which prevents potential contamination. This has the potential to affect all 100 residents living in the Facility. Findings Include: On 1/2/23 at 9:00 AM, during the initial tour of the kitchen, the ice machine did not have an air gap. On 1/2/23 at 9:05 AM, V23 (Dietary Manager) stated, It's a new ice machine. I will call maintenance to look at it. We fill all the drinks from that machine and put food on ice. On 1/2/23 at 11:00 AM, the tray line was observed. The meal was taco salad, and the lettuce was on the steam table. Temperatures were taken of the last tray to come off the tray line. The hamburger was 135 degrees Fahrenheit, the refried beans were 135 degrees Fahrenheit, and the lettuce was 70 degrees Fahrenheit. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain laboratory results documenting the organisms being treated prior to initiating and/or continuing antibiotic therapy for 3 of 23 residents (R69, R91, R94) reviewed for antibiotic stewardship in a sample of 41.